Job Description

SUMMARY

The Grievance & Appeals Intake Coordinator role is primarily responsible for handling the intake of Part C & Part D Grievances and Appeals through various channels. The coordinator is also responsible for generating reporting and tracking the status of open grievance and appeals to ensure their timely resolution. Lastly, the individual would serve as a conduit between the Grievance & Appeals Department and other areas within the organization from which grievances and appeals may originate. You will report to the Grievance & Appeals Manager.

 ESSENTIAL DUTIES AND RESPONSIBILITIES

  1. Daily, review reporting and monitor various communication channels, including call documentation originating from our core membership system, fax, e-mail, and in-person contacts, for potential grievances, CTMs, and appeals that will require handling by the Grievance & Appeals Department.
  2. Intake newly identified grievances and appeals into the Plan’s Grievance & Appeal system, MHK CareProminence. This includes ensuring the case is properly classified, documented, and ensuring all relevant supporting documentation is attached to the case.
  3. Work with staff members from other areas, such as the Call Center, Part D Department, and Health Services Department, to obtain the proper documentation and sufficient information needed to determine proper routing and initiate intake.
  4. Analyze newly received cases to ensure they have been routed and classified correctly. This includes determining whether the case is timely, valid, a duplicate, or whether it should be handled through a process that lies outside of the purview of the Grievance & Appeals Department.
  5. Ensure all misrouted cases are channeled in a timely manner through the appropriate process for resolution (e.g., organization determination, coverage determination, inquiry, etc.).
  6. Engage department leadership from other areas, such as Call Center, Part D Department, and Health Services Department, to calibrate on the intake of grievances and appeals.
  7. Where required, ensure all newly received cases are acknowledged verbally and in writing within the timeframes specified by the State and the Centers for Medicare and Medicaid.
  8. Distribute newly created cases to Grievance & Appeals Coordinators equitably for processing, and assist with the redistribution cases as requested by leadership.
  9. Prepare and present expedited Part C & D appeals to plan medical directors for medical expediency review.
  10. Review Grievance & Appeals system work queue to ensure all cases have been properly closed out within a timely manner.
  11. On a daily basis, review case tracking reporting to ensure all cases are advanced and completed in a timely manner. This includes, but is not limited to, keeping track of cases requiring appointment of representative and waiver of liability documents.
  12. Daily, login to Grievance & Appeals Help Desk queue to attend to calls originating from other departments and to assist with their questions concerning grievance and appeals processes and cases.
  13. Actively participates in both classroom and online training and other educational opportunities as required.
  14. Actively participates in department and organizational meetings as requested.
  15. Complies with the organization's policies and procedures and maintains confidentiality in accordance with state and federal laws.
  16. Participates in special projects and performs other duties as assigned.

Required qualifications

  • Bilingual in Spanish and English.
  • Ability to work a schedule of Monday – Friday, 8:00 a.m. to 5:00 p.m., with flexibility to work occasional overtime per business needs and occasionally work Saturdays and Sundays for on-site/off-site training and projects.
  • At least two (2) years’ experience working with a Medicare Advantage and/or Part D organization, preferably in a customer services and/or health services related role.
  • At least one (1) year experience working in a Medicare Advantage Grievance & Appeals role.
  • Strong data entry skills. Ability to touch-type at a minimum of 60 words per minute.
  • Strong understanding of Centers for Medicare and Medicaid regulatory requirements and guidelines pertaining to the handling of grievances, appeals, and CTMs.
  • Minimum one (1) year of experience working in a call center in insurance managed care, preferably a Medicare HMO.
  • Knowledge of basic medical terminology.
  • Computer Skills:
    • Proficient in the use of customer relations management systems designed for use by health insurance organizations
    • Intermediate to advanced skills in Microsoft Word and Microsoft Excel
    • Minimum of 1+ years of experience working with customer relation management software and/or healthcare records management software 

Preferred qualifications

  • Knowledge and/or experience working with/for the utilization management unit of a health plan or medical center, preferably one that focuses on a Medicare Advantage population.
  • Medical billing and/or coding experience and/or certification.
  • Knowledge and/or experience working with/for the Part D unit of a PBM and/or Medicare Advantage organization, or pharmacy that caters towards a Medicare Advantage population.

EDUCATION

Associate’s Degree or 2 years of relevant experience.

Medical billing and/or medical coding certification a plus.

Health services focused education/certification a plus.

LANGUAGE SKILLS

Bilingual English/Spanish fluency.

CERTIFICATES, LICENSES, REGISTRATIONS

N/A

 PHYSICAL DEMANDS/WORK ENVIRONMENT

Work schedule is approximate and hours/days may change based on company needs. All full-time employees are required to complete forty (40) hours per week as scheduled, including on weekends and holidays. Position requires the ability to work extended hours when necessary.

The physical demands and work environment characteristics described herein are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

This work requires the following physical activities: climbing, bending, stooping, kneeling, twisting, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors.